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UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT 4 <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SER FOR;LOCALAGENCY UsE ONLY " <br /> p Q YES ND REPORT BEEN FLED? YES )HERE91'CERTIFY THAT I AM A DESIGNATED GOVERNMENT EMPLOYEE AND THAT I NAVE:; <br /> �iEPOBTED THI5;tNF MATI0N.7D IQCAI QFF.CIALSTURSUANT;TO SECTXX-:: 5180:7:Df; <br /> REPORT DATE /rte G� CASE s THE HEATH AND S. CODE / -7 ( �y <br /> /.162.1 t �fJ D eY / Y SIGNED <br /> RATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE SIGNATURE <br /> REPRESE G ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME `c <br /> p- LOC <br /> AL AGENCY E] OTHER - �. i e• (,� <br /> a 11 f�G[ a cf6/rc A&III; SerriC t.: <br /> LU <br /> cr ADDRESS <br /> v, 09 /60/9- Hazel /Ir✓P ��� .4 gs�oJ <br /> STREET CRY STATE 21P i <br /> NAME / CONTACT PERSON PHONE <br /> z a vl f'!irk/? Cts 69 - ❑ UNKNOWN -U C /a.)3 <br /> Ra ADDRESS �a <br /> a A), 5hk k/0/-, C19 <br /> STREET CRY STATE 21P =� <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> ADDRESS H ` <br /> 5- N. at)10—/) STREET CITY ��F'n cowry <br /> y� CROSS STREET TYPE OF AREA COMMERCIAL❑INDUSTRIAL❑RURALTYPE OF BUSINESS RETAIL FUEL STATION <br /> `P�nO/I f E::]RESIDENTIAL ❑OTHER T❑ FARM OTHER <br /> LOCALAGENCY AGENCY NAME CONTACTPERSON PHONE <br /> IA'som ill It <br /> S' REGIONAL-20ARD <br /> PHONE f <br /> w (�I f NAME QUANTITY LOST(GALLONS) <br /> r <br /> 7 C>il <br /> UNKNOWN <br /> 0 <br /> H ai: <br /> UNKNOWN <br /> DATE DISCOVERED G] FIOW DISCOVERED ❑ NTORY CONTROL E:] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br /> 0 M A <br /> M -I a DI sv 1 y ❑ TANK TEST TANK REMOVAL Q OTHER <br /> DATE DISCHARGE:BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> Lu M D D r y UNKNOWN ❑ REMOVE CONTENTS El REPLACE TANK CLOSE TANK , <br /> HAS Di , RGE BEEN STOPPED 7 ❑ REPAIR TANK ❑ REPAIR PIPING ❑ CHANGE PROCEDURE <br /> YES ❑ NO IFYES.DATE u1 11 DI DI r y ❑ OTHER <br /> uyr SOURCE OF DISCHARGE TANKS ONLYACAAPACITY MATERIAL <br /> CAUSE(S) iy <br /> ❑ TANK LEAK UNKNOWN GAL, ❑ FI GLASS <br /> ❑ OVERFILL ❑ RUP REIFAILURE <br /> cs PIPING LEAK AGE YRS STEEL ❑ ') <br /> o CORROSION UNKNOWN I, 7 <br /> ' ❑ QTHER ❑ UNKNOWN ❑ OTHER ❑ SPILL ❑ OTHER III. <br /> Lu Im CHECKONEONLY <br /> U UNDETERMINED SOIL ONLY GROUNDWATER DRINKING WATER- (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED)l <br /> CHECK ONSONLY <br /> Ni <br /> Z(n �E <br /> Q 5 ❑ SITE INVESTIGATION IN PROGRESS(DEFINING E)rTENTOF PROBLEM) ❑ CLEANUP IN PROGRESS❑ SIGNED OFF(CLEANUP COMPLETED OR UNNECESSARY)' <br /> ❑ tIO,ACTtON TAKEN ❑ POST CLEANUP MONITORING IN PROGRESS ❑ NO FUNDS AVAC ABLE TO PROCEED Q EVALUATING CLEANUP ALTERNATIVES <br /> CHECK APPROPRIATE ACTION(S)(SEE BACK FOR DETAILS) <br /> ❑ ,CAP SITE(CD) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION it <br /> ❑ CONTAINMENT BARRIER(CB) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT) ❑ REPLACE SUPPLY(RS) Xi <br /> ❑ TREATMENT ATHOOKUP(HU) ❑ NO ACTION REQUIRED(NA) ❑ OTHER(OT) <br />